Frequent co-morbid conditions with asthma. Nelson Rosário MD, PhD, FAAAAI, FACAAI

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1 Frequent co-morbid conditions with asthma Nelson Rosário MD, PhD, FAAAAI, FACAAI

2 Comorbidities in childhood asthma Knowledge is sparse. Further studies are needed: to identify the prevalence the effects of these comorbidities and their treatment on the degree of asthma control in children. de Groot EP et al Eur Respir J 2010; 36: 671-8

3 Asthma comorbid conditions - Share a common pathophysiological mechanism with asthma. - Influence asthma control, its phenotype and response to treatment. - More prevalent in asthmatics but without obvious influence on this disease. - Interaction with A remains to be documented for many of them, particularly for severe A. - If considered relevant, they should be treated appropriately. Expert Rev Respir Med 2011

4 Ocular symptoms and asthma severity 628 (41%) 1 sx of conj. 1257(81%) dx AR 829 (66%) 1 sx of conj. Westphal G et al J Allergy Clin Immunol 2009;123:S129

5 Diagnostic Probability of Reported Allergic Conjunctivitis in 681 Asthmatic Children With Ocular Symptoms * *P< Chong Neto, Rosario et al Ann Allergy Asthma Immunol 2010;105:

6 more than 75% of patients with allergic rhinitis and 20% of patients with asthma have ocular symptoms, such as itching, tearing, and redness Singh K, Bielory L. Ann Allergy Asthma Immunol.2007;98(suppl 1):S1 S125.

7 1549 asthmatic children (59% male; mean age 4.3 years) medical record information: Physician diagnosis of conjunctivitis 15.8% 43.9% had at least 1 ocular symptom that suggested ocular allergy. Chong Neto, Rosario et al Ann Allergy Asthma Immunol 2010;105:

8 Frequency of ocular symptoms Itching 38.4% Tearing 19.9% Redness 25% Combined symptoms: itching plus redness 21.6% itching plus tearing 16.6%.

9 % Allergic Diseases and Severity of Asthma N= Mild Asthma Moderate Asthma Severe Asthma Asthma A + Rhinitis Asthma +AD A + AR +AD Associated Allergic Disease Miyagui R et al 2004

11 Allergic Rhinitis in Asmatics Sensitized to 1 allergen. Asthmatic Children 0-14 y/o n=1543 Asthmatics <2 y/o n=493 (32%) Asthmatics 2 y/o n=1050 (68%) Asmáticos com rinite n=367 (74%) *P=0,11 Asmáticos com rinite n=890 (85%) Asmáticos com P=0,00001 Rinite alérgica Teste cutâneo alérgico + n=131 (36%) Asmáticos com Rinite alérgica Teste cutâneo alérgico + n= 773 (87%)

12 Allergic Rhinitis in Asmatics Sensitized to 1 allergen. Crianças asmáticas 0-14 anos n=1543 Asthmatics <2 y/o n=493 (32%) Asthmatics 2 y/o n=1050 (68%) *P=0,11 With Rhinitis n=367 (74%) With Rhinitis n=890 (85%) Asmáticos com P=0,00001 Rinite alérgica Teste cutâneo alérgico + n=131 (36%) Asmáticos com Rinite alérgica Teste cutâneo alérgico + n= 773 (87%) * Test χ²

13 Allergic Rhinitis in Asmatics Sensitized to 1 allergen. Crianças asmáticas 0-14 anos n=1543 Asthmatics <2 y/o n=493 (32%) Asthmatics 2 y/o n=1050 (68%) *P=0,11 With rhinitis n=367 (74%) With rhinitis n=890 (85%) *P=0,00001 SPT pos+ n=131 (36%) SPT pos+ n= 773 (87%) * Test χ² Chong Neto, Rosario et al. Iran J Allergy Asthma Immunol 2010; 9: 21-5

Treatment of recurrent wheezing infants N=1360; 12-15 months old

14 Treatment of recurrent wheezing infants N=1360; months old Rosário NA & Chong Neto HJ. Allergol et Immunopathol 2009; 34:

15 A asma inicia-se na infância e pode ser confundida com outras causas de sibilância. É possível identificar diferentes fenótipos. Associa-se à inflamação, demonstrável por procedimentos invasivos e não-invasivos Ocorre remodelamento

16 Conjunctivitis A. Rhinitis Nonallergic VCD Atopic Dermatitis BHR ASTHMA Food Allergy GERD Obesity Infections ABPA

17 Conjunctivitis A. Rhinitis Nonallergic VCD Atopic Dermatitis BHR ASTHMA Food Allergy GERD Obesity Infections ABPA

18 Diagnosis of Asthma in Children 5 Years and Younger Symptom patterns (wheeze, cough, breathlessness) which occur recurrently, during sleep, or with triggers such as activity, laughing or crying are consistent with a diagnosis of asthma.

additional predictive support, as early allergic

19 Diagnosis of Asthma in Children 5 Years and Younger The presence of atopy or allergic sensitization provides additional predictive support, as early allergic sensitization increases the likelihood that a wheezing child will have asthma.

20 Airway inflammation in difficult asthma Endobronchial biopsy and BAL in 28 children with persistent obstruction despite ICS Persistent symptoms vs paucisymptomatic Similar RBM thickening Eos. and Neutr. in epithelium: S > PS IFNγ e IFNγ / IL-4 ratio: PS > S Symptoms are associated with Th2 dependent inflammation. De Blic et al J Allergy Clin Immunol 2004

21 Bronchial biopsy (May-Grunwald Giemsa) from a paucisymptomatic child showing intraepithelial and submucosal mononuclear cells (A) and from a symptomatic child showing eosinophils in the intraepithelial and submucosal area (B). Magnification 500. Difficult asthma in children:a biopsy-based study De Blic et al JACI 113:97,2004

22 Are we overtreating recurrent wheezing in infancy? There is an excessively frequent label of asthma in intermittent exclusive virus-induced wheezing in infancy often leading to inappropriate use of steroids There is still under-diagnosis and poor management in children with established asthma. Asthma starts early in life with recurrent wheezing frequent in the first year of life. Phenotypes overlap in this age group, and pediatricians frequently prescribe controller asthma medication regardless of whether symptoms are troublesome or if there is a clear response to treatment. Rosario NA, Chong Neto HJ. Allergol Immunopathol 2009; 3:

24 Allergic Bronchopulmonary Aspergillosis Diagnostic criteria Asthma. Immediate skin reactivity to Aspergillus. Serum precipitins to A fumigatus. Total serum IgE >1.000 ng/ml Current or previous pulmonary infiltrates. Central Bronchiectasis. Peripheral Eosinophilia. Greenberger PA, Patterson R. Ann Allergy 1986; 56:444 8.

25 Allergy 2011; 66: A. fumigatus sensitization was associated with a 2.01 increased hazard ratio of bronchiectasis (95% CI 1.26 to 3.22, P = 0.005), and more obstructive spirometry postbronchodilator FEV1/FVC ratio 57.6 vs 70.3 P = even when diagnostic criteria for ABPA are not met

26 Contents Allergic Rhinitis Allergic Conjunctivitis Inflammation Obesity

history of asthma Severity of EIB: Maximum Fall

27 to assess the frequency and severity of EIB in obese adolescents with or without prior clinical history of asthma Severity of EIB: Maximum Fall in %FEV1 and the area above the curve (AAC 0-30 min )

Cross-sectional study N= 80, ages 10 16 ys Asthmatic obese (n = 18) Asthmatic non-obese (n =21) Obese

in FEV1 (MF%FEV1) and area above the curve (AAC0-30min) were calculated to evaluate EIB severity and recovery.

28 Cross-sectional study N= 80, ages ys Asthmatic obese (n = 18) Asthmatic non-obese (n =21) Obese non-asthmatic (n =26) Healthy individuals (n =15) Exercise bronchoprovocation test : FEV1 15%, maximum % fall in FEV1 (MF%FEV1) and area above the curve (AAC0-30min) were calculated to evaluate EIB severity and recovery. Body Masss Index (BMI) >95 (Center for Disease Control and Prevention (CDC) Lopes et al Allergol Immunopathol 2009;37:175 9

30 Excess weight increased EIB frequency among asthmatic and non-asthmatic adolescents and contributed to severity in EIB.

31 % FEV1 Parameters for EIB evaluation AAC Exercise % EIB (+) Maximum fall in FEV 1-25 Baseline Time (min)

32 Obesity impacted negatively pulmonary function in both asthmatics and non asthmatics after exercise Excess weight in asthmatics significantly contributed to increase in exercise-induced bronchospasm severity and recovery period EIB should be evaluated in obese before initiating a fitness program.

33 Muchas Gracias Prof.Dr. Nelson Rosário

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